Following the tragic deaths of Alphonsine Djiako Leuga and her daughter Loraine Choulla, a Local Child Safeguarding Practice Review (LCSPR) was progressed in respect of Loraine Choulla (referred to throughout the report as ‘Lisa’),
The review was commissioned and overseen by the Nottingham City Safeguarding Children Partnership (NCSCP) and undertaken by an independent author who brought together key NCSCP partners plus associated agencies to review the practice of all agencies involved with the family and identify any learning.
Steve Edwards, Independent Scrutineer at the Nottingham City Safeguarding Children Partnership, said, “The Partnership extends its deepest condolences to the family, friends, and everyone affected by this tragic case. Loraine was described as vibrant, loving, funny, and sociable – a young woman full of joy, creativity and potential. Her death, and that of her mother, is a profound tragedy, and we recognise fully that more must be done to prevent such events happening in the future.
“The review identifies strengths in practice – most notably the compassion and commitment of individual professionals who knew Loraine, and the positive engagement achieved within health and education at various stages.
“However, it also highlights missed opportunities and shortcomings in multi-agency coordination, information-sharing, child protection processes, and in recognising and responding to neglect. Loraine’s communication needs, disabilities and lived experience were not sufficiently understood. Despite periods of intervention, support did not translate into meaningful change, and nor did agencies consistently explore barriers to engagement or consider alternative approaches to reach and understand the family’s circumstances. Loraine’s world became increasingly isolated, and the system was not always able to see or hear her clearly enough.
“The review also highlights the importance of cultural humility and understanding the impact of migration, race, trauma and social isolation. Alphonsine experienced challenges navigating services in a new country, and at times mistrust and fear made engagement difficult. As a partnership we must do more to understand the experiences of families from Black African backgrounds and ensure that children with disabilities and their carers do not face barriers to support. Trusted relationships matter – and we will work to build them.
“We fully accept the recommendations of the review. A series of targeted actions identified in an initial rapid review carried out in 2024 have already been implemented across the Partnership.
“Our commitment is to learn from the findings, challenge ourselves, embed change and ensure that children like Loraine are seen, heard and safeguarded here in Nottingham.”